Paradoxical reaction to epinephrine induced by beta-blockers in an anaphylactic shock induced by penicillin

Anaphylaxis: A 2023 practice parameter update

This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.

Successful treatment of severe adrenaline-resistant anaphylactic shock with glucagon in a patient taking a beta-blocker: a case report

Background

The efficacy of glucagon for adrenaline-resistant anaphylactic shock in patients taking β-blockers is controversial. However, understanding the efficacy of glucagon is important because adrenaline-resistant anaphylactic shock is fatal. We present a case of severe adrenaline-resistant anaphylactic shock in a patient taking a β-blocker, and glucagon was effective in improving hemodynamics.

Case presentation

An 88-year-old woman with severe aortic stenosis and taking a selective β-1 blocker underwent transcatheter aortic valve implantation under general anesthesia. Postoperatively, she received 100 mg sugammadex, but 2 min later developed severe hypotension and bronchospasm. Suspecting anaphylactic shock, we intervened by administering adrenaline, fluid loading, and an increased noradrenaline dose. Consequently, the bronchospasm improved, but her blood pressure only increased minimally. Therefore, we administered 1 mg glucagon intravenously, and the hypotension resolved immediately.

Conclusions

Glucagon may improve hemodynamics in adrenaline-resistant anaphylactic shock patients taking β-blockers; however, its efficacy must be further evaluated in more cases.

Peculiarities of Adverse Events Manifested by Injury of Skin and Skin Derivatives and Associated with Beta-blockers Use

More than 50 years after Propranolol was introduced to the pharmaceutical market as a drug that can lower the heart rate, beta-blockers (BAB) are still widely used in the pharmacotherapy of cardiovascular diseases. However, the use of BAB has a number of limitations, first of all, due to adverse drug events (AE) that develop during their use. The purpose of our review was to study the features of the BAB AE manifested by injuries of the skin and its appendages. The clinical manifestations of them are the development or exacerbation of psoriasis, lichen planus, contact dermatitis, acrocyanosis, Raynaud's disease, alopecia, hyperhidrosis, vitiligo, anaphylaxis, and allergic skin reactions. True medicinal psoriasis occurs in patients taking BAB with no family or previous history and most often mimics erythrodermic psoriasis and palmar-plantar pustular psoriasis. Systemic use of BAB can also be accompanied by exacerbation of vitiligo. In patients with segmental vitiligo, the results of Doppler flowmetry and iontophoresis showed increased blood flow in vitiligo foci compared with normal skin. The development of anaphylactic reactions against the background of BAB therapy may be due to the modulation of adenylate cyclase, which can affect the release of anaphylactogenic mediators, as well as a decrease in the severity of cardiovascular compensatory changes. The peculiarities of the development of such reactions may be the resistance of patients to traditional treatment, which is due to the development of paradoxical reflex vagotonic effects when using adrenaline. Some of the mentioned AE may pose a potential threat to the life and health of the patient and therefore require additional discussion.

Anaphylactic shock in a patient with severe aortic stenosis treated with adrenaline and landiolol for circulatory management: A case report

RATIONALE

We present the first case of a patient with severe aortic stenosis who developed anaphylactic shock and was successfully treated with adrenaline and landiolol, a highly selective β1-receptor blocker, to prevent disruption of the myocardial oxygen supply-demand balance caused by tachycardia.

PATIENT CONCERNS

An 86-year-old woman was scheduled for simultaneous anterior-posterior fixation for a burst fracture of the 12th thoracic vertebra; 200 mg sugammadex, a neuromuscular blocking agent antagonist, was administered postoperatively, and she was extubated without complications. However, 6 min after extubation, her blood pressure decreased abruptly to 55/29 mm Hg, and her heart rate increased to 78 bpm. Then, we intervened with fluid loading, an increased dose of noradrenaline, and phenylephrine administration. However, her blood pressure did not increase.

DIAGNOSES

A general observation revealed urticaria on the lower leg; thus, we suspected anaphylactic shock due to sugammadex administration.

INTERVENTIONS

We carefully administered 2 doses of 0.05 mg adrenaline and simultaneously administered landiolol at 60 μg/kg/min to suppress adrenaline-induced tachycardia. Adrenaline administration resulted in a rapid increase in blood pressure to 103/66 mm Hg and a maximum heart rate of 100 bpm, suppressing excessive tachycardia.

OUTCOMES

The patient's general condition was stable after the intervention, and circulatory agonists could be discontinued the following day. She was discharged from the intensive care unit on the fourth postoperative day.

LESSONS

Landiolol may help control the heart rate of patients with aortic stenosis and anaphylactic shock. The combined use of landiolol and adrenaline may improve patient outcomes; however, their efficacy and risks must be evaluated by studying additional cases.

Management of Anaphylaxis

Anaphylaxis is a severe systemic reaction that can be managed appropriately with expedient diagnosis and treatment. Intramuscular epinephrine continues to be the mainstay of treatment of anaphylaxis; however, it is still underused in the community and in the medical setting. Further education and counseling of patients and health care providers is required to prevent and manage anaphylaxis successfully. In-office management of anaphylaxis includes training of staff, preparedness with the necessary supplies and medication, and an effective action plan.

Kounis syndrome induced by amoxicillin following vasospastic coronary event in a 22-year-old patient: a case report

This article reports the case of a 22-year-old male patient presented with electrocardiographic ST elevation and elevated cardiac biomarkers. The clinical cascade set into events within an hour of administration of a single-dose of amoxicillin on being diagnosed with acute tonsillitis. The case was preliminarily diagnosed and treated according to the acute coronary syndrome protocol, but on performing coronary angiography no abnormalities in the coronary artery were found. Acute myocarditis was excluded in cardiac MRI. Considering possible hypersensitive reaction of amoxicillin in the absence of major cardiovascular risk in the young patient, diagnosis of Kounis syndrome (KS) was inferred. A thorough clinical observation of the patient after stopping the administration of amoxicillin revealed that there was a resolution of ST-elevation towards baseline. It coincided with falling cardiac biomarkers concomitant with subsided pain. The asymptomatic patient was discharged after 5 days of hospital stay. Telephonic follow-up one week after discharge from the hospital confirmed his pain-free and overall normal clinical status. Aim of the present report is to emphasize the need for increased awareness of KS induced by amoxicillin.

Acute Allergic Reactions in Emergency Medical Dispatch Centre: Predictors of Hospitalisation

Introduction

We sought to identify symptoms predictive of hospitalisation of patients having the acute allergic reactions managed by an Emergency Medical Dispatch Centre in France.

Methods

A prospective study was conducted from 20th August 2006 to 5th November 2006 on incoming calls to the Emergency Medical Dispatch Centre for the Hauts de Seine province, France. Statistical analyses were used to identify hospitalisation predictors. The validity of predictors identified was tested. We calculated equivalents of sensitivity (probability of presence of the sign when the reaction is severe), specificity (probability of absence of sign when the reaction is not severe), positive predictive value (probability of severe reaction when the sign is present) and negative predictive value (probability of non-severe reaction when the sign is not present).

Results

A total of 210 calls were included. The following clinical hospitalisation predictors identified had very good specificity and good positive predictive value: facial oedema, sense of choking, respiratory distress, cough, difficulty speaking, dysphagia, abdominal pain, dizziness, collapse, and chest pain. However, none of the selected predictors had a safe negative predictive value (and sensitivity).

Conclusion

This study has identified positive clinical predictors of hospitalisation for acute allergic reactions patients managed by a Medical Emergency Dispatch Centre. The next step will be a multicentre study in order to develop a severity score or a decision-making algorithm. (Hong Kong j.emerg.med. 2014;21:80-87)

Apparent Epinephrine Toxicity in the Treatment of Anaphylaxis: A Patient Case of Prolonged Hypotension

Background

The emergent nature of anaphylaxis creates an environment of heightened risk for epinephrine medication misadventures that may occur in any health care setting. Literature to date has focused on the immediate adverse outcomes associated with epinephrine dosing and administration errors, with a lack of data available on prolonged consequences.

Objective

We present a unique case of refractory hypotension associated with the administration of high-dose epinephrine for the treatment of anaphylaxis that prompted a comprehensive safety evaluation and implementation of a process improvement plan for all patients experiencing an anaphylactic reaction in our institution.

Case Report

A 29-year-old female presented to an immediate care facility for treatment of anaphylaxis including 2 doses of epinephrine 1 mg (1:1000) intramuscularly. The patient was subsequently transported to our adult emergency department and developed isolated hypotension refractory to fluid resuscitation. The patient was then admitted to the medical intensive care unit with a diagnosis of epinephrine toxicity. The prolonged hypotensive response seen in this patient is believed to be a result of residual stimulation of the more sensitive beta receptors by high doses of epinephrine administered to the patient, resulting in a prolonged vasodilatory response.

Conclusion

Epinephrine is a high-alert medication used for the treatment of anaphylaxis. Proactive evaluation of current processes among institutions is recommended in order to minimize dosing and administration errors with epinephrine as these errors can lead to substantial harm to patients.

Outpatient aspirin desensitization for patients with aspirin hypersensitivity and cardiac disease

BACKGROUND

Cardiac disease is common and often treated with aspirin therapy. Patients who develop an immunoglobulin E (IgE) hypersensitivity reaction to aspirin must abort treatment and receive alternative antithrombotic agents. Aspirin desensitization is a therapeutic procedure that may allow patients with a history of hypersensitivity to safely resume aspirin treatment. A variety of inpatient desensitization protocols have been published for IgE-mediated reactions, but outpatient regimens have not been previously reported.

OBJECTIVE

We aimed to determine the efficacy and safety of a multiday outpatient aspirin desensitization protocol for patients with an IgE-mediated aspirin hypersensitivity.

METHODS

We retrospectively assessed the efficacy of a multidose aspirin desensitization protocol performed in a university allergy-immunology clinic between July 2006 and December 2009. Patients were referred for a diagnosis of aspirin hypersensitivity and required aspirin for cardiac disease treatment. The protocol involved 10 or 12 aspirin doses depending on the final dose of 81 or 325 mg. Patients were desensitized over 2 to 3 half-days and were able to return home in between desensitization sessions.

RESULTS

A total of 9 patients with cardiac disease and aspirin hypersensitivity underwent an outpatient multiday aspirin desensitization. Eight patients (89%) were successfully desensitized and 1 patient declined to continue with further desensitization. No adverse reactions requiring inpatient hospital care occurred during desensitization.

CONCLUSIONS

This novel outpatient multiday aspirin desensitization protocol was a safe and effective approach for the treatment of aspirin hypersensitivity in patients with cardiac disease who require aspirin therapy. This flexible protocol is convenient for patients by avoiding hospital admission and full-day time commitments.

Clopidogrel Hypersensitivity: A Novel Multi-Day Outpatient Oral Desensitization Regimen

BACKGROUND

Clopidogrel hypersensitivity has posed a problem for the acute treatment and long-term care of a particular patient population with coronary artery disease and stent placement. Patients with clopidogrel hypersensitivity have had an increased risk of hypersensitivity reactions, including anaphylaxis, if they ingest clopidogrel without undergoing an oral desensitization procedure. The previously published desensitization protocols have either been performed in the intensive care unit, requiring significant cost and healthcare utilization, or have required a full-day outpatient commitment on behalf of the patient.

OBJECTIVE

To determine whether a multi-day outpatient oral clopidogrel desensitization protocol is effective and safe for patients with clopidogrel hypersensitivity.

METHODS

gWe retrospectively assessed the efficacy of a 10-dose outpatient multiday clopidogrel desensitization protocol performed in a university allergy-immunology center from April 2006 to October 2008 in patients with clopidogrel hypersensitivity. Patients were desensitized over 2–3 half-day clinical visits and were able to go home between desensitization sessions. A preliminary cost analysis was performed using the average of actual costs for the outpatient clopidogrel desensitization procedure and was compared with the average cost for an inpatient oral desensitization completed at our institution.

RESULTS

Eight patients with coronary artery disease, cardiac stent placement, and clopidogrel hypersensitivity underwent an outpatient multi-day oral clopidogrel desensitization procedure. All patients were successfully desensitized with the multi-day protocol without complications. No patient had recurrence of allergic reaction 3 months after the procedure. A preliminary cost analysis demonstrated a lower cost for the outpatient compared to the inpatient oral clopidogrel desensitization protocol.

CONCLUSIONS

This outpatient 10-dose multi-day clopidogrel desensitization protocol is a safe and effective novel approach for the treatment of clopidogrel hypersensitivity in patients with coronary artery disease and cardiac stent placement. In addition to safety and efficacy, this protocol offers the patient the convenience of avoiding hospital admission or full-day time commitments.

Do beta-blockers really enhance the risk of anaphylaxis during immunotherapy?

Both beta-blockers and allergen immunotherapy are frequently prescribed, and allergy/immunology physicians commonly encounter patients who are candidates for immunotherapy and are receiving beta-blockers. The evidence in the medical literature indicates that although anaphylaxis does not appear to be more frequent, beta-blocker exposure is associated with greater risk for severe anaphylaxis, and for anaphylaxis refractory to treatment. Use of beta-blocker suspension merits consideration to reduce risk for untoward outcomes, while supplanting the beta-blocker medication with an equally efficacious non-beta-blocker alternative. For patients who require a beta-blocker for an indication for which there is no equally effective substitute, a management decision by the physician prescribing allergen immunotherapy should be approached carefully from an individualized risk-benefit standpoint.